Robot-assisted partial nephrectomy for T1b tumors: Trifecta results
Abstract
For a long time, direct comparison of various operational methods by means of a consistent analysis of individual performance indicators was considered standard. On the other hand, the concept of high efficiency implies a cumulative result of treatment. The term “trifecta” (3 main factors) evaluating the results of partial nephrectomy refers to the achievement of a negative surgical margin, minimal decreases in renal function and the absence of complications. This article outlines the results of a single-center study on robot-assisted partial nephrectomy (RARP) in stage T1b, indicating the achievement of the already mentioned effects of treatment.
Material and methods. A retrospective analysis of patients with kidney tumors of stage T1b is presented: tumor >4 cm, but <7 cm in the largest dimension, which was performed by RAPN by one surgeon. The study evaluated short-term functional and oncological results, as well as analyzed preoperative, intraoperative and postoperative data. Patients with no >II grade complications according to the modified Clavien–Dindo classification, heat ischemia time (VTI) <25 min, postoperative change in glomerular filtration rate (GFR) <15% and a negative surgical margin, achieved strict criteria for “trifecta” results.
Results. A total of 109 patients underwent RAPN, of which 41 patients had tumors with a tumor size of 4 to 7 cm. The mean VTI was 20.14±9.2 min and the blood loss was 296.09±241.88 ml. Surgical margin was negative in all patients. A decrease in GFR >15% was observed in 12 (29.3%) patients after surgery. 11 (26.8%) patients had VTI for more than 25 min. 5 (12.1%) patients had >II grade complications according to Clavien–Dindo. 23 (60%) patients had rigorous “trifecta” results. The mean follow-up was 44.7±26.1 months. Recurrence of the tumor was not observed in any patient.
Conclusion. Robot-assisted partial nephrectomy for tumors in the T1b stage can be safely performed by experienced hands. Optimal rigorous trifecta results can be achieved without violating oncological principles.
Keywords:robot-assisted partial nephrectomy, kidney tumor, trifecta
For citation: Pogosyan R.R., Malkhasyan V.A., Semenyakin I.V., Prokopovich M.A., Pushkar D.Yu. Robot-assisted partial nephrectomy for T1b tumors: Trifecta results. Clin Experiment Surg. Petrovsky J. 2019; 7 (2): 15–23. doi: 10.24411/2308- 1198-2019-12002. (in Russian)
Received 18.03.2019. Accepted 22.04.2019.
References
1. Ljungberg B., Bensalah K., Canfield S., et al. EAU Guidelines on renal cell carcinoma: update. Eur Urol. 2015; 67: 913–24.
2. Marszalek M., Meixl H., Polajnar M., et al. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. Eur Urol. 2009; 55: 1171–8.
3. Gill I.S., Kavoussi L.R., Lane B.R., et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007; 178: 41–6.
4. Aboumarzouk O.M., Stein R.J., Eyraud R., et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and metaanalysis. Eur Urol. 2012; 62: 1023–33.
5. Masson-Lecomte A., Yates D.R., Bensalah K., et al. Robot-assisted laparoscopic nephron sparing surgery for tumors over 4 cm: operative results and preliminary oncologic outcomes from a multicenter French study. Eur J Surg Oncol. 2013; 39: 799–803.
6. Semenyakin I.V., Pushkar D.Yu., Malhasyan V.A., Prokopovich M.A. Alphabet of renal surgery: ABC score. Pacific Medical Journal. 2017; 2 (68): 68–9 (in Russian).
7. Hung A.J., Cai J., Simmons M.N., Gill I.S. «Trifecta» in partial nephrectomy. J Urol. 2013; 189: 36–42.
8. Kim D.K., Kim L.H.C., Raheem A.A., et al. Comparison of trifecta and pentafecta outcomes between T1a and T1b renal masses following robot-assisted partial nephrectomy (RAPN) with minimum one year follow up: can RAPN for T1b renal masses be feasible? PLoS One. 2016; 11: e0151738.
9. Porpiglia F., Mari A., Bertolo R., et al. Partial nephrectomy in clinicalT1b renal tumors: multicenter comparative study of open, laparoscopic, and robot-assisted approach (the RECORd Project). Urology. 2016; 89: 45–51.
10. Levey A.S., Stevens L.A., et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009; 150: 604–12.
11. Ficarra V., Novara G., Secco S., et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol. 2009; 56: 786–93.
12. Patel M.N., Krane L.S., Bhandari A., et al. Robot partial nephrectomy for renal tumors larger than 4 cm. Eur Urol. 2010; 57: 310–6.
13. Gupta G.N., Boris R., Chung P., et al. Robot-assisted laparoscopic partial nephrectomy for tumors greater than 4 cm and high nephrometry score: feasibility, renal functional, and oncological outcomes with minimum 1 year follow-up. Urol Oncol. 2013; 31: 51–6.
14. Petros F., Sukumar S., Haber G.P., et al. Multi-in- stitutional analysis of robot assisted partial nephrectomy for renal tumors > 4 cm versus ≤ 4 cm in 445 consecutive patients. J Endourol. 2012; 26: 642–46.
15. Ficarra V., Bhayani S., Porter J., et al. Robot-assisted partial nephrectomy for renal tumors larger than 4 cm: results of a multicenter, international series. World J Urol. 2012; 30: 665–70.
16. Janda G., Deal A., Yang H., et al. Single institution experience with robotic partial nephrectomy for renal masses greater than 4 cm. J Endourol. 2016; 30: 384–9.
17. Bi L., Zhang C., Li K., et al. Robotic partial nephrectomy for renal tumors larger than 4 cm: a systematic review and metaanalysis. PLoS One. 2013; 8: e75050.
18. Yossepowitch O., Thompson R.H., Leibovich B.C., et al. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol. 2008; 179: 2158–63.
19. Lopez-Costea M.A., Fumado L., Lorente D., et al. Positive margins after nephron-sparing surgery for renal cell carcinoma: long-term follow-up of patients on active surveillance. BJU Int. 2010; 106: 645–8.
20. Bernhard J.C., Pantuck A.J., Wallerand H., et al. Predictive factors for ipsilateral recurrence after nephron- sparing surgery in renal cell carcinoma. Eur Urol. 2010; 57: 1080–6.
21. Bensalah K., Pantuck A.J., Rioux-Leclercq N., et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol. 2010; 57: 466–71.
22. Tabayoyong W., Abouassaly R., Kiechle J.E., et al. Variation in surgical margin status by surgical approach among patients undergoing partial nephrectomy for small renal masses. J Urol. 2015; 194: 1548–53.
23. Marszalek M., Carini M., Chlosta P. ,et al. Positive surgical margins after nephron-sparing surgery. Eur Urol. 2012; 61: 757–63.
24. Smith G.L., Kenney P.A., Lee Y., et al. Non-clamped partial nephrectomy: techniques and surgical outcomes. BJU Int. 2011; 107: 1054–8.
25. Mottrie A., De Naeyer G., Schatteman P., et al. Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours. Eur Urol. 3010; 58: 127–32.
26. Tobis S., Knopf J.K., Silvers C.R., et al. Near infrared fluorescence imaging after intravenous indocyanine green: initial clinical experience with open partial nephrectomy for renal cortical tumors. Urology. 2012; 79: 958–64.